COVID-19 at War: The Joint Forces Operation in Ukraine

The impact of conflict on infectious disease: a systematic literature review

BACKGROUND

Conflict situations, armed or not, have been associated with emergence and transmission of infectious diseases. This review aims to identify the pathways through which infectious diseases emerge within conflict situations and to outline appropriate infectious disease preparedness and response strategies.

METHODS

A systematic review was performed representing published evidence from January 2000 to October 2023. Ovid Medline and Embase were utilised to obtain literature on infectious diseases in any conflict settings. The systematic review adhered to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analysis). No geographical restrictions were imposed.

FINDINGS

Our review identified 51 studies covering AIDS, Hepatitis B, Tuberculosis, Cholera, Coronavirus 2, Ebola, Poliomyelitis, Malaria, Leishmaniasis, Measles, Diphtheria, Dengue and Acute Bacterial Meningitis within conflict settings in Europe, Middle East, Asia, and Africa since October 2023. Key factors contributing to disease emergence and transmission in conflict situations included population displacement, destruction of vital infrastructure, reduction in functioning healthcare systems and healthcare personnel, disruption of disease control programmes (including reduced surveillance, diagnostic delays, and interrupted vaccinations), reduced access by healthcare providers to populations within areas of active conflict, increased population vulnerability due to limited access to healthcare services, and disruptions in the supply chain of safe water, food, and medication. To mitigate these infectious disease risks reported preparedness and response strategies included both disease-specific intervention strategies as well as broader concepts such as the education of conflict-affected populations through infectious disease awareness programmes, investing in and enabling health care in locations with displaced populations, intensifying immunisation campaigns, and ensuring political commitment and intersectoral collaborations between governments and international organisations.

CONCLUSION

Conflict plays a direct and indirect role in the transmission and propagation of infectious diseases. The findings from this review can assist decision-makers in the development of evidence-based preparedness and response strategies for the timely and effective containment of infectious disease outbreaks in conflict zones and amongst conflict-driven displaced populations.

FUNDING

European Centre for Disease Prevention and Control under specific contract No. 22 ECD.13,154 within Framework contract ECDC/2019/001 Lot 1B.

Prehospital Lessons From the War in Ukraine: Damage Control Resuscitation and Surgery Experiences From Point of Injury to Role 2

The ongoing war in Ukraine presents unique challenges to prehospital medical care for wounded combatants and civilians. The purpose of this article is to identify, describe, and address gaps in prehospital care, casualty evacuation, and medical evacuation throughout Ukraine to share lessons for other providers. Observations and experiences of medical personnel were collected and analyzed, focusing on pain management, antibiotic use, patient assessment, mass casualty triage, blood loss, hypothermia, transport immobilization, and clinical governance. Gaps identified include limited access to pain management, lack of antibiotic guidance, inadequate patient assessment and triage, access to damage control resuscitation and blood, challenged transport immobilization practices, and challenges with clinical governance for both local and foreign providers. Improved prehospital care and casualty and medical evacuation in Ukraine are required, through increased use of empiric pain management, focused antibiotic guidance, enhanced patient assessment and triage in the form of training, access to prehospital blood, and better transport immobilization practices. A robust and active lessons learned program, trauma data capture, and quality improvement process is needed to reduce preventable morbidity and mortality in the war zone. The recommendations presented in this article serve as a starting point for improvements in prehospital care in Ukraine with potential to change prehospital training for the NATO alliance and other organizations operating in similar areas of conflict. Graphical Abstract.

Social disparities and inequalities in healthcare access and expenditures among Iranians exposed to sulfur mustard: a national study using spatio-temporal analysis

BACKGROUND

Sulfur Mustard (SM) is a chemical warfare agent that has serious short-term and long-term effects on health. Thousands of Iranians were exposed to SM during the eight-year Iran-Iraq conflict and permanently injured while the socioeconomic imbalance in their healthcare utilization (HCU) and health expenditures remains. This study aims to describe the HCU of SM-exposed survivors in Iran from 2018 to 2021; identify high-risk areas; and apply an inequality analysis of utilization regarding the socioeconomic groups to reduce the gap by controlling crucial determinants.

METHODS

From Oct 2018 to June 2021, the Veterans and Martyrs Affairs Foundation (VMAF) recorded 58,888 living war survivors with eye, lung, and skin ailments. After cleaning the dataset and removing junk codes, we defined 11 HCU-related variables and predicted the HCU for the upcoming years using Bayesian spatio-temporal models. We explored the association of individual-level HCU and determinants using a Zero-inflated Poisson (ZIP) model and also investigated the provincial hotspots using Local Moran's I.

RESULTS

With ≥ 90% confidence, we discovered eleven HCU clusters in Iran. We discovered that the expected number of HCU 1) rises with increasing age, severity of complications in survivors' eyes and lungs, wealth index (WI), life expectancy (LE), and hospital beds ratio; and 2) decreases with growing skin complications, years of schooling (YOS), urbanization, number of hospital beds, length of stay (LOS) in bed, and bed occupancy rate (BOR). The concentration index (CInd) of HCU and associated costs in age and wealth groups were all positive, however, the signs of CInd values for HCU and total cost in YOS, urbanization, LOS, and Hospital beds ratio groups were not identical.

CONCLUSIONS

We observed a tendency of pro-rich inequity and also higher HCU and expenditures for the elderly population. Finally, health policies should tackle potential socioeconomic inequities to reduce HCU gaps in the SM-exposed population. Also, policymakers should allocate the resources according to the hotspots of HCU.

Excess mortality in Ukraine during the course of COVID-19 pandemic in 2020-2021

In this work, the COVID-19 pandemic burden in Ukraine is investigated retrospectively using the excess mortality measures during 2020-2021. In particular, the epidemic impact on the Ukrainian population is studied via the standardized both all-cause and cause-specific mortality scores before and during the epidemic. The excess mortality counts during the pandemic were predicted based on historic data using parametric and nonparametric modeling and then compared with the actual reported counts to quantify the excess. The corresponding standardized mortality P-score metrics were also compared with the neighboring countries. In summary, there were three "waves" of excess all-cause mortality in Ukraine in December 2020, April 2021 and November 2021 with excess of 32%, 43% and 83% above the expected mortality. Each new "wave" of the all-cause mortality was higher than the previous one and the mortality "peaks" corresponded in time to three "waves" of lab-confirmed COVID-19 mortality. The lab-confirmed COVID-19 mortality constituted 9% to 24% of the all-cause mortality during those three peak months. Overall, the mortality trends in Ukraine over time were similar to neighboring countries where vaccination coverage was similar to that in Ukraine. For cause-specific mortality, the excess observed was due to pneumonia as well as circulatory system disease categories that peaked at the same times as the all-cause and lab-confirmed COVID-19 mortality, which was expected. The pneumonias as well as circulatory system disease categories constituted the majority of all cases during those peak times. The seasonality in mortality due to the infectious and parasitic disease category became less pronounced during the pandemic. While the reported numbers were always relatively low, alcohol-related mortality also declined during the pandemic.

Health and Safety Threats to Ukraine From Nonconventional Weapons: A Clear and Present Danger

This Viewpoint discusses the potential for use of nonconventional warfare threats (chemical, biological, radiological, nuclear, and explosives) in the conflict in Ukraine and how health care professionals need to recognize and respond to these threats.

Hospitalizations of Ukrainian Migrants and Refugees in Poland in the Time of the Russia-Ukraine Conflict

BACKGROUND

In the face of a sudden influx of several million migrants and war refugees from Ukraine to other European countries, knowledge about the health of Ukrainian citizens becomes increasingly important. The aim of the study is to identify the main health problems of hospitalized Ukrainian citizens residing in Poland in the period from 2014 to June 2022.

METHODS

This study is based on hospitalization data of Ukrainian patients in Poland taken from the Nationwide General Hospital Morbidity Study.

RESULTS

The study group covered 8591 hospitalization records. We observed two hospitalization peaks, one in patients aged 0-5 and the other one in those aged 20-35. After the official outbreak of the war, 2231 Ukrainian citizens were hospitalized in Poland. At this time, the most often reported principal reasons for the hospitalizations of adult women were diseases related to pregnancy, childbirth and the puerperium, whereas in groups of adult men diseases were related to injury, poisoning and certain other consequences of external causes, and in children and adolescents diseases were infectious and parasitic diseases.

CONCLUSIONS

Our findings may have implications for healthcare policies and service provision to newly arrived migrants and war refugees in target European countries.

Health Risks During Ukrainian Humanitarian Crisis

Background

The unprecedented exodus in the history of the European Union of more than 6 million Ukrainian refugees (May 13, 2022) is a cause for concern and could lead to a new difficult situation in terms of infectious disease control. Following the SARS-CoV-2 pandemic, Europe is facing a new challenge that could lead to a new wave of COVID-19 and an increase in the number of cases of tuberculosis or eradicated diseases, such as polio.

Aim

The purpose of this analysis was to provide an overview of lung diseases and health risks that could be encountered in refugees from Ukraine and translated to European Union`countries.

Methods

A systematic review was conducted in PubMed, World Health Organization, the UN Refugee Agency and the government's websites. Selected publications investigated the health problems arising from Ukrainian population migration from conflict areas and their impact on the public health system in the adoptive countries. The main potentially contagious diseases in Ukraine have also been reviewed.

Results

The population of Ukraine has serious public health problems such as SARS-CoV-2 infection, multidrug-resistant tuberculosis, high levels of drug resistance and difficulties with an effective vaccination program, so there are significant risks of developing epidemics in transit or host countries. The current crisis has major peculiarities because the migrants were not concentrated in the camps but there was a dispersion of them on large territories of European countries.

Conclusion

In order to meet the health needs of refugees, it is necessary to adapt health systems culturally and linguistically, to train health workers on the particularities of existing diseases in the countries of refugee origin, and to facilitate collection of medical data on migrants' health.

A Historical Review of Military Medical Strategies for Fighting Infectious Diseases: From Battlefields to Global Health

The environmental conditions generated by war and characterized by poverty, undernutrition, stress, difficult access to safe water and food as well as lack of environmental and personal hygiene favor the spread of many infectious diseases. Epidemic typhus, plague, malaria, cholera, typhoid fever, hepatitis, tetanus, and smallpox have nearly constantly accompanied wars, frequently deeply conditioning the outcome of battles/wars more than weapons and military strategy. At the end of the nineteenth century, with the birth of bacteriology, military medical researchers in Germany, the United Kingdom, and France were active in discovering the etiological agents of some diseases and in developing preventive vaccines. Emil von Behring, Ronald Ross and Charles Laveran, who were or served as military physicians, won the first, the second, and the seventh Nobel Prize for Physiology or Medicine for discovering passive anti-diphtheria/tetanus immunotherapy and for identifying mosquito Anopheline as a malaria vector and plasmodium as its etiological agent, respectively. Meanwhile, Major Walter Reed in the United States of America discovered the mosquito vector of yellow fever, thus paving the way for its prevention by vector control. In this work, the military relevance of some vaccine-preventable and non-vaccine-preventable infectious diseases, as well as of biological weapons, and the military contributions to their control will be described. Currently, the civil-military medical collaboration is getting closer and becoming interdependent, from research and development for the prevention of infectious diseases to disasters and emergencies management, as recently demonstrated in Ebola and Zika outbreaks and the COVID-19 pandemic, even with the high biocontainment aeromedical evacuation, in a sort of global health diplomacy.

Long-Term Immunogenicity of Inactivated and Oral Polio Vaccines: An Italian Retrospective Cohort Study

Oral and inactivated poliovirus (PV) vaccines have contributed toward the global eradication of wild PV2 and PV3, as well as the elimination of PV1 in most countries. While the long-term (>5−10 years) persistence of protective antibodies in ≥80% of the population vaccinated with ≥3−4 doses of oral poliovirus vaccine (OPV) has been demonstrated, the duration of immunity in people vaccinated with the inactivated poliovirus vaccine (IPV) is still unclear. This study evaluated the seroprevalence of anti-PV neutralizing antibodies and the long-term immunogenicity conferred by OPV and IPV in a sample of medical students from the University of Bari (April 2014−October 2020). The levels of neutralizing PV1, PV2, and PV3 antibodies in blood samples taken during the assessments were evaluated. Neutralizing antibodies against PV1, PV2, and PV3 were present in >90% of the study participants, with rates of >99%, >98%, and ~92−99%, respectively. IPV resulted in a higher immunological response than OPV against PV3. Protective antibodies against all three viruses persisted for at least 18 years after administration of the last vaccine dose. Until PV1 is completely eradicated, maximum vigilance from public health institutions must be maintained.

Perceived Stress Levels among Ukrainian Migrant and LGBT+ Minorities in Poland during the COVID-19 Pandemic

The Coronavirus disease 2019 (COVID-19) pandemic, immigrant status and being a member of the LGBT+ community are all independent factors associated with increased stress levels. Few studies provide more complex analysis on this issue, and there has been no research on the cumulative burden of perceived stress that people belonging to both minorities experience in the current epidemiological situation. The aim of this study was to assess the ability to deal with an external situation during the third wave of the COVID-19 pandemic in Poland in the following groups with different stress levels (total sample n = 370): Polish heterosexual men (n = 202), heterosexual men from Ukraine (n = 131) and homo- and bisexual men (men who have sex with men-MSM) from Ukraine (n = 37). A Perceived Stress Scale (PSS-10) was used. The analysis of the survey did not show statistically significant differences between the three study groups in the general level of perceived stress (24.71, 24.77 and 26.49 points, respectively, p = 0.551), but it revealed numerous differences in coping with various aspects of everyday functioning between these groups. Negative assessment of one's own health proved to be the main factor negatively affecting the level of perceived stress, however specific health risks, medical history or the participants' previous experience have not been taken into account in the study. Our research shows differences in the needs, resources and methods of coping with stress between men who are Polish citizens and migrants from Ukraine, both heterosexual and belonging to the MSM group. Proper identification and addressing of these needs, taking into account different availability of health services, could be the responsibility of NGOs or insurance providers. This should result in the reduction of mental health burdens and the risk of developing serious mental disorders, and consequently in better functioning of persons belonging to minorities and in a reduced burden on the health care system.